You may attend any camp time on a daily basis regarless of which time you select!

Contact Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address (primary):(will not be shared - only used to communicate with you about camp, food logs, etc.) *

Email Address (secondary - not required):

Phone Number: (for postponed/rescheduled class updates) *

Date of Birth (MM/DD/YY): *

Age: *

Occupation: *

Emergency Contact (Name): *

Emergency Contact (Phone): *

Body Weight & Goals

Height: *

Current Weight: *

Goal Weight: *

What are your health and fitness goals? Check all that apply: *

Achieve balance in life

Control blood pressure

Control cholesterol

Exercise regularly

Feel better overall

Improve cardiovascular fitness

Improve flexibility

Improve muscle tone

Improve nutritional habits

Improve productivity

Increase muscle mass

Increase Strength and endurance

Injury rehab

Reduce body fat

Reduce stress

Reduce back pain

Stop smoking

OtherOther

Physical Activity & Nutrition

Activity Level *

How often do you eat fast food? *

Do you have a good understanding of what nutrients and what proportions should be planned into each meal?*

Medical Information

Regular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. To help us determine if you should consult with your doctor before starting an exercise program at Body Bionics, please read carefully and honestly answer the following questions. All information will be kept confidential.

Please complete the following:*

Yes

No

N/A

Has a physician ever told you or are you aware that you have a heart condition?

Yes

No

N/A

Have you ever experienced a stroke?

Yes

No

N/A

Do you or have you smoked within the last six months?

Yes

No

N/A

Do you have high blood pressure?

Yes

No

N/A

Do you have high cholesterol?

Yes

No

N/A

Has anyone in your immediate family (parents, brothers, sisters) had a heart attack, stroke or cardiovascular disease before the age of 65 (if you are a woman) or 55 (if you are a man)?

Yes

No

N/A

Do you have diabetes?

Yes

No

N/A

Do you have a joint or bone problem that may be made worse by a change in your physical activity?

Yes

No

N/A

Are you a female over 54 years of age or a male over 44 years of age?

Yes

No

N/A

Do you consider yourself to have an inactive lifestyle?

Yes

No

N/A

Are you overweight?

Yes

No

N/A

Do you have any of the following: asthma, epilepsy, emphysema or arthritis? If yes, list below.

Yes

No

N/A

Do you feel pain in your chest when you engage in physical activity?

Yes

No

N/A

Do you feel pain in your chest when you are NOT engaged in physical activity?

Yes

No

N/A

Have you ever had unusual shortness of breath at rest or with mild exertion?

Yes

No

N/A

Do you ever suffer from dizziness or fainting spells?

Yes

No

N/A

Are you currently taking medications? If yes, list below.

Yes

No

N/A

Women: Are you pregnant or have you been pregnant within the last three months?

Yes

No

N/A

Notes: If you answered YES to any of the questions above, please provide as much detail as possible in the field below for each YES answer. It is not uncommon for Medical Releases to be requested. So please help us properly determine if one might be necessary. IF YOU ARE REGISTERING THE DAY BEFORE CAMP BEGINS, PLEASE CONTACT US VIA PHONE AFTER YOU SUBMIT ONLINE. We must review your medical history responses prior to any admission to the boot camp.

I have answered the above accurately and completely. I understand that my medical history is an important factor in the development of my fitness program and that certain medical/physical conditions which are known to me, but which I do not disclose to Body Bionics may result in serious injury to me. If any of the above conditions change, I will immediately inform Body Bionics. I, knowingly and willingly, assume all risk of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the above questionnaire.

Waiver of Liability & Informed Consent

I have enrolled in a program of strenuous physical activity including but not limited to cardiovascular and resistance training by Body Bionics. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this exercise program. In consideration of my participation in the exercise program, I for myself, my heirs and assigns, hereby release Body Bionics and its partners* from any claims, demands and causes of action arising from my participation in the exercise program by Body Bionics. I fully understand that I may injure myself as a result of my participation in the exercise program and I hereby release Body Bionics and its partners* from any liability now or in the future including but not limited to heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat related injuries/illnesses, knee/foot/low back injuries and any other illness, soreness or injury however caused, occurring during or after my participation in the exercise program.In addition, I understand that Body Bionics frequently captures images of its boot camp sessions and participants via photo and/or video. I am aware that these images may contain photos and/or videos of me. I further understand that Body Bionics owns these images and the right to use them for marketing purposes including but not limited to website postings and printed materials.*Partners include but are not limited to businesses and or organizations that provide access to and use of their facilities where Body Bionics hosts exercise programs. By registering, I acknowledge that I have read, understand and agree with the above statements and conditions and agree to abide by them.